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    Document   : Incident1
    Created on : Jul 2, 2011, 1:32:59 AM
    Author     : Nadesh
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<h1 align="center">Surveillance of DF-DFH - Case Investigation Form</h1>
<p align="center" class="Level2">EPIDIMIOLOGY UNIT, MINISTRY OF HEALTH</p>
<blockquote>
  <blockquote>
    <blockquote>
      <p><strong>To be completed by the ICNO or any other responsible officer in the ward on discharge or removal of patient.</strong></p>
      <p><strong>Necessary data should be obtained from the Consultant, Medical Officers, BHT, Diagnosis card of the patient or from</strong></p>
      <p><strong>the parent/guardian.</strong></p>
      <p>.</p>
      <form id="Incident1" name="Incident1" method="post" action="/EpidStats/Incident2.jsp">
          
      <p>Name of Hospital:    
        <label for="Hospital"></label>
        <input name="hospital" type="text" id="hospital" size="80" />
      </p>
      <p>Case no. given in the notification register:  
        <input name="caseno" type="text" id="caseno" size="20" />
      </p>
          
      <p>.</p>
      <p><strong>A. PARTICULARS OF THE PATIENT</strong></p>
      <p>1) Name:  
        <input name="name" type="text" id="name" size="80" />
        
      </p>
      <p>2) Date of Birth (dd mm yyyy): 
        <input name="d1" type="text" id="d1" size="1" maxlength="1" />
        <input name="d2" type="text" id="d2" size="1" maxlength="1" /> 
        &nbsp; 
        <input name="m1" type="text" id="m1" size="1" maxlength="1" /> 
        <input name="m2" type="text" id="m2" size="1" maxlength="1" /> 
        &nbsp; 
        <input name="y1" type="text" id="y1" size="1" maxlength="1" /> 
        <input name="y2" type="text" id="y2" size="1" maxlength="1" /> 
       
        <input name="y3" type="text" id="y3" size="1" maxlength="1" />
        <input name="y4" type="text" id="y4" size="1" maxlength="1" />
      </p>
      <p>3) Sex: 
        
        <label for="ethnicity"></label>
   
          <label>
            <input name="sex" type="radio" id="sex_0" value="female" checked="checked" />
          Female</label>
          <label>
            <input type="radio" name="sex" value="male" id="sex_1" />
          Male</label>
          <label>
            <input type="radio" name="sex" value="unknown" id="sex_2" />
          Unknown</label>
      </p>
      <p>4) Ethnicity:
        <label for="ethnicity"></label>
        <label>
          <input name="ethnicity" type="radio" id="sex_3" value="sinhala" checked="checked" />
        Sinhala</label>
        <label>
          <input type="radio" name="ethnicity" value="tamil" id="sex_4" />
          Tamil</label>
        <label>
          <input type="radio" name="ethnicity" value="moor" id="sex_5" />
          Moor</label>
        <label>
          <input type="radio" name="ethnicity" value="others" id="sex_6" />
          Others</label>
        <label>
          <input type="radio" name="ethnicity" value="unknown" id="sex_7" />
          Unknown</label><br />
          <br />
          5) 
        
Occupation:  
        
        <input name="occupation" type="text" id="occupation" size="70" />
        
<br />
      </p>
      <p>6) Residential Address:
        <input name="address" type="text" id="address" size="80" />
      </p>
      <p>7) District: 
        <select name="district" id="district">
          <option value="Colombo" selected="selected">Colombo</option>
          <option value="Matara">Matara</option>
          <option value="Ampara">Ampara</option>
          <option value="kandy">Kandy</option>
          <option value="Kurunagalle">Kurunagalle</option>
          <option value="Vavuniya">Vavuniya</option>
          <option value="Trincomalee">Trincomalee</option>
          <option value="Jaffna">Jaffna</option>
          <option value="Hambantota">Hambantota</option>
        </select>        
      </p>
      <blockquote>
        <blockquote> 
          <p>&nbsp;</p>
          <p align="right"><a href="javascript:getdone()">Next</a></p>
          </form>
          <hr align="center">
          </hr>
          <div align="center" class="small-font">&copy; copyright 2011| Epidemiology Unit | all right reserved</div>
          <p align="right">&nbsp;</p>
        </blockquote>
      </blockquote>
    </blockquote>
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